HomeMy WebLinkAboutWELL-03-2018-096560.TIF WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple welts RECEIVED
I.Well Contractor Information:
Michael W. Shaw2 2Q18 14.WATER ZONES
(prr3 FROM TO �. DESCRIPTION
Well Contractor Name
Ai.,,,_
I Il ft. r'7 T7 it. 2
3232 e-° .crit"• uuUNT' -T .9t. LV t.
NC Well Contractor Cenilication Number `(; L,:M_MTAL HEALTH 15.OUTER CASING(for molted wells)OR LINER(if ap Ilea ble)
'tT NV FROM TO DIAMETER THICKNESS MATERIAL
Advanced Well Drilling, LLC 0 ft. /Dft. S In. Heavy PVC
Company Name 16.INNER CAVING OR TUBING(geothermal closed-loop)
D?Ira
6 FROM TO I DIAMETER THICKNESSMATERIAL2.Well Construction Permit k: 7 y (t. ft. in. —
List all applicable mall cmmntrtion permits(i.e.Counitt State.;thence.etc.)
ft. ft. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. In.
OAgricultuml OMunicipaL/Public
°Geothermal(Head a/Cooling Supply) °Residential Water Supply(single) ft. R. in.
°Industrial/Commercial OResidendal Water Supply(shared) IS.GROUT
FROM TO I MATERIAL EMPLACESIENT METHOD @AMOUNT
°Irrigation a f'. 2.0- 1 Bentonite Poured
Non-Water Supply Well:
°Monitoring 0Recovep, ftn. I
Injection Well: rt. n.
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
UI(er SlOm. FROM TO I MATERIAL ESIPLAC&MP.NT METHOD
°A
q ge and Recovery °Salinity Barrier ft ft.
°Aquifer Test OSlormwater Drainage
rt. ft. I
°Experimental Technology °Subsidence Control
°Geothermal(Closed Loop) 20.DRILLING LOG(attach additional sheets If necessan)
°Tracer FROM TO DESCRIPTjON In r.hada
ress.soivrvel one.graintin.etc)
°Geothermal(Heating/Cooling Rerun)) °Other(explain under#21 Remarks) `fir r'. r, C. - 1 )
4.Date Well(s)Completed:11 i \hell IDg �r� R. ary t.
5a.Well Location: / n. ft. I - y
rt
1
/t—LS V!n / O,4 Pt J ft. rt.
111IIIFacility/Owner Na.to t /� Facility lD-(if piicable) —
1 yy� ft. R.
75/74 St= ,-es/✓A 1)CUtcy ll ft. ft.
Physical A•.rcss.City,a I Zip 21.REMARKS
. i ••''' ..,005-,7O7.2y
CountParcel Identification No.(PIN)
5b.Latitude and Longitude hl degrees/minutes/seconds or decimal degrees:
(if well field.one Iatilong is sufficient)
g ??.Cyr' °/ion:
Signature of Ccnified Well Contractor Date
6.Is(are)the well(s): °Permanent or °Temporary
8v signing this font,/hereby ceni f that the well(s)was(were)enommeted in accordance
with ISA NC:IC 02C.0100(Jr 154 NCAC 02'.0200 R ell Construction Standards and that a
7.Is this a repair to an existing well: ❑yes or o epi of this recon/has been pmeided,e the well comer.
If this is a repair.fill out btorw well construction information and explain dee nature of Me
repair under 021 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or ria ontersimph.wel/s ONLY vide the same construction.you can
submit onefarm. �C��' SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (/ o j (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderenl(erentple-3 (00'and-(ti)/001 construction to the following:
10.Static water level below top of casing: M to (ft.) Division of Water Quality,Information Processing Unit,
Ifouter level u abort casing.use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
//�� \ above. also submit a copy of this form within 30 days of completion of well
12.Well construction method: //'f./"' R V'"y construction to the following:
(i.e.auger,rosary.cable.direct push.etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY NCLLS ONLY: 1636 Mail Sen-ice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) , Method of test: Air 24c.For Water Sum:ly&Injection Wells: In addition to sending the form to
(/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: completion of well construction to the county health department of the county
�'lb
where constructed.
Tom GW-I Nonh Carolina Department of Environment and Natural Resources-Division of Water Quality •
Revised Jan.2013